Faculty Bibliography

This study examined the procedural validity of DTREE, a microcomputer-based expert system that guides the user through the diagnostic logic of DSM-III-R. A DTREE-guided DSM-III-R diagnosis of 20 inpatients (made by the treating clinician) was compared with a 'standard' diagnosis made simultaneously during a weekly 2-hour case conference consisting of a presentation by the treating clinician and other staff, a chart summary, and the administration of the Structured Clinical Interview for DSM-III-R (SCID), and culminating in a group consensus diagnosis. The kappa agreements were .80 for schizophrenia (N = 10), .83 for major depression (N = 3), and -.08 to 1.00 for other disorders. These results suggest that DTREE can produce valid assessments, at least in an acute setting of primarily patients with schizophrenia

OBJECTIVE: Because aggressive behaviors of psychiatric patients may be caused by environmental or biological factors, treatment plans that incorporate medication and behavior therapies are the most effective. The authors review research on pharmacological and behavioral treatments for aggressive patients and present a decision tree for use on behavioral units to direct treatment of such patients. METHODS: The empirical literature was searched for studies of pharmacological and behavioral interventions that have been shown to have some value for treating this problem. RESULTS AND CONCLUSIONS: Psychiatrists must proceed cautiously because no medication has been approved by the Food and Drug Administration specifically for treatment of aggression. Antipsychotics, lithium, antidepressants, sedatives, anxiolytics, anticonvulsants, opiate antagonists, and beta blockers have been used, often depending on the etiology of the aggression, such as head injury or dementia. Although some drugs such as buspirone and propranolol show promise; side effects must be monitored. Three behavioral strategies have effectively reduced aggression in the inpatient milieu. The token economy is perhaps the most comprehensive behavioral tool for producing a well-structured milieu. Aggression replacement strategies help patients learn alternative responses. Decelerative techniques teach strategies that enable the patient to reduce aggression quickly. The authors describe a decision tree to guide decisions about pharmacological and behavioral treatments of aggression depending on where in the course of the disorder patients exhibit difficulty.

Deficiency of hexosaminidase A causes the GM2 gangliosidosis known as Tay-Sachs disease. It is now known that this condition has several late-onset variants that cause numerous neuropsychiatric disturbances. Early recognition is important because treatment with phenothiazines and heterocyclic antidepressants may worsen the course. The authors report two cases with several new findings, including prominent psychiatric symptoms without psychosis early in the course of the illness.

Irritability, angry affect, and aggressive behavior are commonly associated with cocaine abuse. The authors describe neurobiological mechanisms that may explain this association. They also recommend guidelines for the assessment and treatment of patients who display cocaine-related aggressive activity.

Emotional and cognitive symptomatologies, such as depression, mania, lability of mood and affect, psychosis, impaired arousal, anxiety, and irritability and aggression often occur in neurologic disorders. These neuropsychiatric syndromes significantly impair functioning and efforts at rehabilitation. Patients with brain damage are especially sensitive to the side effects of medication. When appropriate guidelines are followed, psychopharmacologic intervention alleviates these symptoms, enhances rehabilitation, and avoids impairment of arousal and cognition.